Optimal Resources for Metabolic and Bariatric Surgery

Optimal Resources for Metabolic and Bariatric Surgery 2019 Standards facs.org/mbsaqip AMERICAN COLLEGE OF SURGEONS AMERICAN COLLEGE OF SURGEONS AMERICAN COLLEGE OF SURGEONS AMERICAN COLLEGE OF SURGEONS AMERICAN COLLEGE OF SURGEONS AMERICAN COLLEGE OF SURGEONS AMERICAN COLLEGE OF SURGEONS A AMERICAN COLLEGE OF SURGEONS Optimal Resources for Metabolic and Bariatric Surgery 2019 Standards Copyright © 2019 American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611-3295. All rights reserved. Table Foreword ii MBSAQIP Designations and Accreditation Pathways vi of Contents Designations vii Designation Requirements Overview viii Accreditation Pathways x Standard 1 Institutional Administrative Commitment 1 1.1 Administrative Commitment 3 Standard 2 Program Scope and Governance 5 2.1 Volume Criteria 7 2.2 Low Acuity Center Patient and Procedure 9 Selection 2.3 Ambulatory Surgery Center Patient and 10 Procedure Selection 2.4 Metabolic and Bariatric Surgery (MBS) Committee 11 2.5 Metabolic and Bariatric Surgery (MBS) Director 13 2.6 Metabolic and Bariatric Surgery (MBS) 15 Coordinator 2.7 Metabolic and Bariatric Surgery (MBS) Clinical 16 Reviewer 2.8 Obesity Medicine Director (OMD) 18 Standard 3 Facilities and Equipment Resources 21 3.1 Health Care Facility Accreditation 23 3.2 Facilities, Equipment, and Furniture 24 3.3 Designated Bariatric Unit 26 Standard 4 Standard 6 Personnel and Services Resources 29 Data Surveillance and Systems 59 4.1 Credentialing Guidelines for Metabolic and 31 6.1 Data Entry 61 Bariatric Surgeons 6.2 30-Day and Long-Term Follow-Up 62 4.2 MBSAQIP Surgeon Verification 33 6.3 Data Review 63 4.3 Metabolic and Bariatric Surgery Call Coverage 35 6.4 Obesity Medicine Data Collection 64 4.4 Staff Training 36 4.5 Multidisciplinary Team 37 Standard 7 4.6 Advanced Cardiovascular Life Support (ACLS) 38 Quality Improvement 67 4.7 Patient Stabilization 39 7.1 Adverse Event Monitoring 69 4.8 Critical Care Unit (CCU) / Intensive Care Unit 40 7.2 Quality Improvement Initiatives 70 (ICU) Services 7.3 Annual Compliance Reports (ACRs) 72 4.9 Anesthesia Services 41 4.10 Endoscopy Services 42 Standard 8 4.11 Diagnostic and Interventional Radiology Services 43 Education: Professional and Community Outreach 75 4.12 Specialty Services 44 8.1 Support Groups 77 4.13 Pediatric Medical Advisor (PMA) 45 4.14 Pediatric Behavioral Specialist 46 Accreditation Definitions 78 4.15 Children’s Hospital Service Requirements 47 Accreditation Process Overview 79 MBSAQIP Accreditation Process for Initial 79 Standard 5 Applicants Patient Care: Expectations and Protocols 49 MBSAQIP Reaccreditation Process for Renewal 79 5.1 Patient Education Pathways 51 Applicants 5.2 Patient Care Pathways 52 5.3 Written Transfer Agreement 53 5.4 Inpatient Admitting Privileges 54 5.5 Risk Assessment Protocol 55 5.6 Obesity Medicine Services 56 MBSAQIP-Accredited centers demonstrate an uncompromising pursuit of quality that has earned the confidence, respect and trust of patients making a commitment to healthier living. It’s better for your patients. for your surgeons. for your center. i Optimal Resources for Metabolic and Bariatric Surgery | 2019 Standards | American College of Surgeons The Optimal Resources for Metabolic and Bariatric Surgery Foreword outlines requirements for facilities to follow when seeking accreditation. MBSAQIP Accreditation provides guidance The American College of Surgeons (ACS) and the American for facilities aiming to build the structure and outcomes Society for Metabolic and Bariatric Surgery (ASMBS) are expertise necessary to provide safe, efficacious, and high- pleased to offer the latest Standards for the Metabolic and quality care to all metabolic and bariatric patients. Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP®), a nationwide accreditation and quality improvement program for the treatment of metabolic and bariatric patients. The MBSAQIP builds upon the Background on ACS and ASMBS rich history of these organizations in advancing surgical patient care, and the previous success of their individual About the American College of Surgeons accreditation and quality improvement programs. The American College of Surgeons (ACS) is a scientific and educational organization of surgeons that was founded in Through their collaborative efforts, the ACS and the ASMBS are 1913 to raise the standards of surgical practice and improve confident that by working together with the facilities, physicians, the quality of care for all surgical patients. The College is and health care professionals who provide care to the more dedicated to the ethical and competent practice of surgery. than 18 million people in the United States who are affected Its achievements have significantly influenced the course of by obesity, they are able to answer the call to action to address scientific surgery in America and have established it as an obesity as a national public health priority and serve as the important advocate for all surgical patients. The College has medical home for all patients with obesity. more than 82,000 members and is the largest organization of surgeons in the world. For more information, visit facs.org. Currently, there are more than 800 MBSAQIP-Accredited centers in the United States and Canada, and multiple About the American Society for Metabolic and Bariatric international centers participating as Data Collection Surgery Centers. More than 200,000 bariatric cases are captured The American Society for Metabolic and Bariatric Surgery annually in the MBSAQIP Registry. (ASMBS) is the largest organization for metabolic and bariatric surgeons in the world, with more than 4,200 Multiple studies have examined patient safety in metabolic members. It is a not-for-profit organization that works to and bariatric surgery and support the value of accreditation. advance the science of metabolic and bariatric surgery. The An article in Surgical Endoscopy (July 2013) found that in- ASMBS is committed to educating medical professionals hospital mortality rates at accredited centers were more than and the lay public about metabolic and bariatric surgery, three times lower than the mortality rates at non-accredited including the associated risks and benefits, as a treatment centers (0.06% vs. 0.22%). University of California Irvine option for obesity. The ASMBS encourages its members to researchers conducting this study analyzed 277,760 metabolic investigate and discover new advances in metabolic and and bariatric procedures performed between 2006 and 2010. bariatric surgery while maintaining a steady exchange of Additionally, an October 2012 publication in the Journal of experience and ideas that may lead to improved surgical the American College of Surgeons showed nearly the same outcomes for patients with obesity. For more information, differences in mortality rates between accredited and non- visit asmbs.org. accredited academic metabolic and bariatric surgery centers (0.06% vs. 0.21%, respectively). American College of Surgeons | 2019 Standards | Optimal Resources for Metabolic and Bariatric Surgery ii Metabolic and Bariatric Surgeon Contributors Acknowledgements Stacy Brethauer, MD, FACS, FASMBS Eric DeMaria, MD, FACS, FASMBS This 3rd version of the MBSAQIP Standards Manual Wayne English, MD, FACS, FASMBS is dedicated to Ronald “Ronnie” Clements, MD, FACS, Karen Flanders, MSN, CNP, CBN FASMBS. Matthew Hutter, MD, FACS, FASMBS Teresa LaMasters, MD, FACS, FASMBS As Co-Chair of the MBSAQIP Standards Committee, he Samer Mattar, MBBCh, FACS, FASMBS was instrumental in developing the inaugural version of Marc Michalsky, MD, FACS, FASMBS the Optimal Resources for Metabolic and Bariatric Surgery. John Morton, MD, FACS, FASMBS Memories of his warm personality, clinical excellence, and Richard Peterson, MD, FACS, FASMBS indomitable spirit will continue as an inspiration to all who Anthony Petrick, MD, FACS, FASMBS care for patients with obesity. David Provost, MD, FACS, FASMBS Aurora Pryor, MD, FACS, FASMBS Bruce Wolfe, MD, FACS, FASMBS Obesity Medicine Physician Contributors Caroline Apovian, MD, FACP, FACN Louis Aronne, MD, FACP Scott Butsch, MD, MSc John Cleek, MD, FTOS Angela Fitch, MD, FACP Deborah Horn, DO, MPH Scott Kahan, MD, MPH Christopher Still, DO, FACN, FACP, FTOS ACS Staff Contributors Clifford Y. Ko, MD, MSHS, FACS, Director, Division of Research and Optimal Patient Care Sameera Ali, MPH, Administrative Director, Division of Research and Optimal Patient Care Teresa Fraker, MS, RN, Program Administrator, MBSAQIP Paul Jeffers, BA, Verification Specialist, MBSAQIP These Standards are intended solely as qualification criteria for MBSAQIP Accreditation. They do not constitute a standard for care and are not intended to replace the medical judgment of the surgeon or health care professional in individual circumstances. In order for a center to be found compliant with the MBSAQIP Standards, the center must be able to demonstrate compliance with the entire Standard as outlined in the Definition and Requirements, Documentation, and Measure of Compliance sections under each Standard. The Documentation and Measure of Compliance sections under each Standard are intended to provide summary guidance on how compliance must be demonstrated but are not intended to stand alone or supersede the Definition and Requirements. In addition to verifying compliance with the Standards as written in this manual, the MBSAQIP may consider other factors not stated herein when reviewing a center for accreditation and reserves the right to

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